欢迎来到留学生英语论文网

当前位置:首页 > 论文范文 > Nursing

Intensive Case Management versus biomedical within the mental health

发布时间:2017-03-17
该论文是我们的学员投稿,并非我们专家级的写作水平!如果你有论文作业写作指导需求请联系我们的客服人员

A service issue within a case management context that would be of concern to both client and professionals alike, is the process in determining which model would be best fit for a client. It is of concern for the client to know which model is the best approach for them, and which would prove most useful and benifical to assist them and their current needs. The two main models impact professional social workers in the way they present their work and manage their clients, whether it be a team approach, or more of an individual approach. It is the workers reponsibility in assessing the clients needs, to determine which case management model is the best approach for that individual client.

Case management specifically in a mental health field is defined as "the administration of care for an outpatient individual with a serious mental illness to a single person (or team); this includes coordinating all necessary medical and mental health care, along with associated supportive services" (Case Management, 2007).

Case management began as a way of assisting clients to move their way through the service system with the help of professionals, with the implication that social workers were the professionals that "know everything" because of their special expertise, and clients "don't know." This was very disempowering, since it was assumed that these individuals could not fix their issues independently and had to rely on case workers. Faulkner (2007), has found, specific to nursing practice, that "disempowering interventions led to learned helplessness effects within the mealtime event akin to patient dependence." While Hartman (1994), pointed out that as health and human service providers, we are obligated to examine potential ways that we may inadvertently, actually disempower our clients, by stressing our "expert" role and the power of our knowledge. As well Hartman said "we must learn to bracket our knowledge, to put it aside so it wil not shape ourquestions and our listening and cause a barrier between us and the people we would understand" (Hartman, 1994).

Depending on the specific setting and circumstances, case managers are responsible in completing some of the following, such as referring clients to services, or sometimes they must provide intensive clinical or rehabilitative services themselves. Other potential tasks include outreach to engage clients in services, assessing individuals needs, monitoring medication, and arranging support services (such as housing, or job training), and advocating for client rights and entitlements (Ziguras, Stephen J. and Geoffrey W. Stuart, 2000).

Case management is not limited by time but rather is a service, intended to be continuous, providing clients with support for as long as necessary. Case management has continued to be dominated by a biomedical approach, although there is much criticis; such as its tendency to "medicalize" particular human conditions like aging, tendency to label people, and has the goal of patient/client compliance. To given an overview briefly of the main differences between the ACT model and the Intensive Case Management Model-ICM has individual staff, and uses a generalist discipline, while ACT uses a multidisiplinary team approach. ICM emphasizes outreach in assisting clients to access needed services and providing advocacy as needed, while ACT often provides services directly to their clients (Case Management, 2007).

The ACT model has emphasis in providing intensive treatment and support services within, for an ongoing, open-ended period of time, which stresses medication compliance and the adherence to a treatment plan developed by a psychiatrist. "Staffing is intensive, utilizing an inter-disciplinary team that includes a psychiatrist and nurse with a shared caseload" (Case Management, 2007). Intensive case management is based off an empowerment approach, while the ACT model has established itself as a biomedical approach (Ziguras, et. al., 2000).

An Introduction to the Issue:

In the last 60 years, there have been major changes in the mental health system. In the 1950s, mental health care for persons with severe and persistent mental illnesses (like schizophrenia , bipolar disorder , severe depression, and schizoaffective disorder ) was provided almost exclusively by psychiatric hospitals. Hospitals provided a wide range of primary supports in addition to mental health treatment, including housing, meals, and clothing, and varying degrees of social rehabilitation (Case Management, 2007).

Neuroleptic medications were eventually introduced to the public. The medications provided symptomatic management of psychosis, delusions, and hallucinations; but these medications are not cures and sometimes symptoms never fully diminish even with the support of medication. Reforms in the mental health policy, including the introduction of Medicare 1965 and the Supplemental Security Income [SSI] program in 1974, provided ways for policy makers to discharge patients into the community and transfer mental health fees to the federal government. These changes, included safeguards for involuntary patients, court decisions established the right to treatment in the least restrictive setting, and changes in the philosophies of care ultimately led to widespread deinstitutionalization . In 1955 there were 559,000 persons in state hospitals; and by 1980, that number had dropped to 132,000 (Case Management, 2007).

Recent data from the U.S. Center for Mental Health Services, has stated that the number of mental health organizations providing 24-hour services, including both hospital inpatient and residential treatment, has doubled in the United States from 1970 to 1998, as well the amount of psychiatric beds provided by these organizations has been reduced by 50% (Ziguras, et. al., 2000). Deinstitutionalization policies, have resulted in a rise in the number of patients discharged from hospitals, as well a reduced length of stay for newly admitted patients. It is more common in todays society for patients to be sent to a complex and decentralized system of community-based care, rather than to the hospital. Case management was designed to modify the confusion created by multiple care providers in different settings, and to guarantee accessibility, continuity of care, and responsibility for individuals with long-term severe mental illnesses.

Two models of case management which appear most often in the mental health literature are Assertive Community Treatment (ACT) and Intensive Case Management (ICM). Another model, clinical case management, refers to a program where the case manager assigned to a client also functions as their primary therapist. Both models have criticisms and have the potential to be coercive, in reinforcing dependency and learned helplessness instead of promoting independence for their clients (Case Management, 2007).

A Critical Examination/Comparison of the Issue:

The Biomedical Model/ ACT team

The ACT model was first started in an inpatient research unit at Mendota State Hospital in Madison, Wisconsin in the late 1960s. Created by, Arnold Marx, Leonard Stein, and Mary Ann Test, their goal was to produce a "hospital without walls." In an ACT model, a group of a minimum of 8 to a maximum of 12 professionals work as a team including case managers, a psychiatrist, nurses, social worker, vocational specialist, ocupational therapist, addiction specialist, peer specialist and a mental health clinician (Ziguras, et. al., 2000). These professionals are assigned continuous shift work 24 hours a day, seven days a week, 365 days a year, for a caseload of approximately fifty to eighty clients with severe and persistent mental illnesses.

ACT uses multidisciplinary teams, has a low client-to-staff ratio, an emphasis on assertive outreach, provision of in-vivo services (in the client's own setting), assistance with ADL (activities of daily living) skills, emphasis on relationship building, and emotional support, assistance in managing the clients illness, crisis intervention when necessary, providing clients with services rather than linking them to other serivces (Case Management, 2007).

Compared to other psychosocial interventions the ACT model has a significantly strong evidence base. "Twenty-five random controlled clinical trials have proven that these programs reduce homelessness, hospitalization, including inappropriate hospitalization; increase housing stability; control psychiatric symptoms; and improve quality of life, especially among individuals who are high users of mental health services." Assertive Community Treatment teams can now be found in countries such as, USA, Canada, the UK, and Australia (Case Management, 2007).

Intensive case management

Intensive case management practices are typically targeted to individuals with the greatest service needs, including individuals with a history of multiple hospitalizations, people with dual diagnosis such as an addiction and a severe mental illness. As well as individuals with mental illness who have been involved with the criminal justice system, and individuals who are both homeless and severely mentally ill are commonly serviced by ICM models (Case Management, 2007).

"A recent (2002) mail survey of 22 experts found that while intensive case management shares many simularities with ACT programs, its elements are not as clearly stated" (Case Management, 2007). ACT tends to rely more heavily on a team versus an individual approach, as well Intensive case managers are more likely to refer their clients to rehabilitation services rather than provide them directly, like an ACT team would. Lastly Intensive case management programs are more likely to focus on client strengths, empowering clients to fully participate in all treatment decisions, while often ACT teams may have to force their clients to follow their individual recovery plan, which has been order by a doctor in order to avoid getting admitted to the hospital (Schaedle, Richard, John H. McGrew, Gary R. Bond, and Irwin Epstein, 2002).

ACT team clients are often on Community Treatment Orders, which are doctor ordered for a person to receive treatment or care and supervision in the community. The treatment and supervision is based on a community treatment plan which outlines the medications, medical appointments and other aspects of care the doctor believes is necessary to allow the person to live in the community rather than remain in the hospital (Schaedle, et. al., 2002).

. Thus these clients are often disempowered; if they do not want to abide by their treatment plan they are bound to be a risk of being "formed" and sent back to the psychiatric unit within their local hospital (Case Management, 2007).

Clinical case management

A meta-analytic study which compared the ACT model with clinical case management found that while the common approach resulted in increased hospital admissions, it significantly decreased the length of stay, suggesting that the overall impact of clinical case management is positive (Schaedle, et. al., 2002). The study concluded that both ACT and clinical case management should be essential features of any mental health service system. One of the biggest downfalls of deinstitutionalization has been that many families, often become case managers for their own family members without any training or support in how to manage their loved one.

Case management for children and adolescents

Case management is also used to organize care for children with serious emotional disturbances that have the potential to harm a child's ability to function socially, and academically. Case management has been primarily focused on service use rather than clinical outcomes, since there has been limited research on case management for children and youth with these serious mental illnesses there is increasing evidence that case management is an effective intervention for this population (Case Management, 2007).

A model used for children which is one of many case management approaches is called "wraparound." Helping families develop a plan to address the child's individual needs across several life areas including at home and at school, in one of the many strategies this model uses. Research on the effectiveness of this model is still in an early stage (Case Management, 2007). Another model, known as the children and youth intensive case management (YICM) or expanded broker model had been evaluated in two direct studies. Findings suggest that the YICM model results in behavioral improvements among children with mental illnesses as well as fewer days in hospital a settings (Schaedle, et. al., 2000).

Conclusion

In recent years, many case management programs have expanded their teams to successfully include clients as peer counselors and family members as outreach workers. While the ACT model offers the strongest evidential base for its effectiveness, research on intensive case management is ongoing.

The sufficiency of any case management model depends on the access to treatment and the avaliable support services in the neighbourhood, the organization and management of the service system, and on the ability of an individual or family to pay for care often through public supports such as ODSP, or entitlement programs. Compared to traditional outpatient programs, case management also offers a level of care that is far more comprehensive and humane for disadvantaged populations.

Sources

Case Management. (2007). Encyclopedia of mental disorders. Retrieved February 28, 2011, from http://www.minddisorders.com/Br-Del/Case-management.html

Faulkner, M. (2007). The onset and allieviation of learned helplessness in older hospitalized people. University of Sheffield. Retrieved February 27, 2011 from: http://nursinglibrary.org/Portal/main.aspx?pageid=40

Hartman, A. (1994). Reflection and Controversy: Essays on Social Work. Washington, D.C. National Association of Social Workers.

Schaedle, Richard, John H. McGrew, Gary R. Bond, and Irwin Epstein, (2002). "A Comparison of Experts' Perspectives on Assertive Community Treatment and Intensive Case Management." Psychiatric Services 53, no. 2: 207- 210.

Ziguras, Stephen J. and Geoffrey W. Stuart, (2000). "A Meta-Analysis of the Effectiveness of Mental Health Case Management Over 20 Years." Psychiatric Services 51, no. 11, 1410-1421.

上一篇:返回列表 下一篇:Unethical Practices And Conflicts Of Interest In The Pharmaceutical Industry